Why is this toolkit needed

Over the past decade, the Registered Nurses' Association of Ontario (RNAO) has consistently advocated for maximum integration and utilization of the NP role throughout the health system to improve patient outcomes and system effectiveness.

Amendments to Regulation 965 of the Public Hospitals Act, 1990 showcase Ontario as the first jurisdiction in Canada to legally authorize nurse practitioners (NP) to admit, treat and discharge hospital inpatients. A two-stage process set the stage for the discharge authority on July 1, 2011 while the authority for NPs to admit came into effect on July 1, 2012. The changes improved patient flow and system effectiveness in hospitals by providing equitable and timely access to care. However, despite this regulatory framework, as well as strong research regarding NP effectiveness, implementation of the role in hospitals has been sporadic [1].

Given the significant challenges facing the health-care system today, as well as the shift towards interprofessional care, it is untenable to limit the effective utilization of available health-care professionals. As will be explored further in this toolkit, expected outcomes of full utilization of NPs in hospitals include improved access to care, reduced wait times, improved patient safety, improved quality of care, improved patient satisfaction and reduced costs.

Studies suggest adequate planning and stakeholder understanding are key to facilitating NP utilization in health-care settings [1]. Toolkits, such as this, enable successful implementation of NP utilization by providing NPs and hospital administrators with:

  • Key primary documents (e.g., relevant legislation and regulations),
  • Summary of evidence regarding the quality of NP care of hospital patients
  • Economic analysis of integrating NPs into care of hospital patients, including a cost-benefit analysis
  • Policy analysis (e.g., position statements by professional associations)
  • Jurisdictional review including guiding documents from international jurisdictions such as New Zealand, Australia, the United Kingdom and the United States
  • Practical tools for implementation and evaluation (collaborative practice agreements, slide deck presentations to hospital boards, prototype by-laws), and
  • Case studies from hospitals that have successfully implemented NP admit, treat and discharge authority.

Thus many tools are needed to effectively plan, implement and evaluate NP utilization in hospitals that ultimately improves hospital services through better access to care.

How was the toolkit developed?

In the spring of 2011, the Registered Nurses’ Association of Ontario (RNAO), in collaboration with NPAO, formed a task force co-chaired by Vanessa Burkoski, Chief Nurse Executive (CNE) at the London Health Sciences Centre, and Michelle Acorn, then President of NPAO. The task force engaged CNEs and NPs from rural and urban community hospitals across Ontario, to facilitate adoption of regulation 965 amendments and advance the full utilization of NPs in Ontario hospitals. The Nurse Practitioner Utilization in Hospitals Toolkit was launched February 13, 2012 and published online, based on the current state of knowledge with the intent to remain evergreen and responsive to further legislative and regulatory changes.

In October 2014, RNAO’s Home Office held a one-day event titled "Nurse Practitioners in Hospitals: Knowledge Exchange Symposium," with representation from 18 health-care organizations from across Ontario.  The symposium’s objectives were to examine strategies to increase the utilization of Regulation 965 in Ontario, including how this toolkit can help hospitals fully implement NPs. RNAO staff also solicited feedback through a survey to Ontario hospital CNEs to guide the re-working of the toolkit.  The following edition of the toolkit, version 2.0, is a reflection of that feedback, as well as other key improvements to facilitate full utilization of NPs in hospitals.

Who are the potential users of the toolkit?

  • This toolkit has been developed to help a wide range of organizations and health-care teams to implement the NP role in hospital inpatient settings.
  • Toolkit users may include NPs, hospital administrators, interprofessional care providers, nursing leaders and health-care managers, government policy-makers, health-care planners, NP educators and researchers.

How will this toolkit help?

Users of this toolkit may:

  • Determine the impact of introducing NPs utilization in Ontario hospitals.
  • Consider their response to significant questions before implementing NPs in hospitals.
  • Identify the legal and regulatory issues involved with NP utilization in Ontario hospitals.
  • Create customized bylaws, collective practice agreements and presentations using the templates provided.
  • Establish a plan to clearly identify and communicate NP roles and responsibilities in the hospital setting.
  • Create a business case and sustainable budget to implement NPs in the hospital setting.
  • Design a method to evaluate the impact of NPs on outcomes including quality and safety improvement, patient satisfaction, patient flow, value and organizational effectiveness.
  • Consider innovative roles for NPs that are enabled by legislative and regulatory changes.
  • Have input into future revisions of this toolkit by providing continuous feedback on the documents selected and recommendations for additional documents that should be added.

Strategies for getting the most out of this toolkit [2]

  • Keep in mind that this toolkit should be used as a flexible health-care planning guide. The use of steps, activities and tools is meant to be enabling rather than prescriptive. Each organization or health-care planning team can select and/or adapt the specific activities and tools to best fit their circumstances.
  • You can use the toolkit by moving sequentially through each section, or start with the section that best fits the context of your health-care planning situation. Health-care planning is not a linear process and each section is not a discrete step. You may find it necessary to revisit earlier sections from time to time as you move through the toolkit.
  • You may not need to use each tool as you may have some work already completed. For example, your organization may have already considered the questions in the discharge elements document, as part of their strategic planning process.
  • There are numerous tools that you can use throughout the toolkit. You will be guided to different parts of the toolkit when appropriate.



  1. DiCenso, A. and D. Bryant-Lukosius, Clinical Nurse Specialists and Nurse Practitioners in Canada: A Decision Support Synthesis. 2010, Canadian Health Services Research Foundation.: Ottawa, ON.
  2. Cancer Care Ontario. APN Roles in Cancer Control Toolkit. 2011; Available from: